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http://dx.doi.org/10.2147/JPR.S63570

Paraplegia after intercostal neurolysis with phenol

Lakshman GollapalliRudramanaidu MuppuriDepartment of Anesthesiology and Pain Medicine, Wayne State University/Detroit Medical Center, Detroit, MI, USA

Correspondence: Lakshman Gollapalli Department of Anesthesiology, Wayne State University/Detroit Medical Center, 3990 John R Road, Detroit, MI 48201, USA Tel +1 313 745 7233 Email lgollapa@med.wayne.edu; lakshman.bme@gmail.com

Abstract: In patients with advanced stages of cancer, severe pain is commonly encountered

and is very difficult to treat. It affects the quality of life of the patient and the families involved.

Pain can be managed using analgesics and adjuvant therapy. However, studies have shown that

at least 10%–15% of patients fail to control pain adequately and will experience severe pain.

We discuss the case of a 66-year-old female with metastatic adenoid cystic carcinoma of the left

submandibular gland and developed paraplegia following intercostal neurolysis with phenol.

After a successful diagnostic T6 to T12 intercostal nerve block, the patient was scheduled for

an intercostal neurolytic block. We injected 2 mL of 10% aqueous phenol at each level on the

left from the T6 to T12 ribs. One hour after the procedure, the patient developed bilateral lower

extremity weakness with difficulty moving. A physical examination showed the absence of

sensation to pinpricks and vibration from T10 to S5 and an absence of anal sphincter tone and

sensation. Magnetic resonance images of the thoracic and lumbar spine showed leptomeningeal

metastatic disease and myelitis. We postulate that the paraplegia could be from phenol diffusing

along either the spinal nerves or the paravertebral venous plexus into the subarachnoid space.

This case report points to the risks involved with phenol neurolysis close to the spine, and we

propose alternative methods to minimize neurological complications.

Keywords: intercostal neurolysis, pain, phenol, paraplegia

IntroductionSevere pain is a frequently encountered symptom that affects the quality of life for

advanced cancer patients. It has been estimated that 60%–90% of all patients dying

of cancer will experience pain in the terminal phase of their disease.1–3 Pain can be

managed using analgesics and adjuvant therapy titrated according to the World Health

Organization’s analgesic ladder.4

When pain is resistant to standard therapy or when severe side effects of analgesics

occur, alternative analgesic techniques should be considered. These include regional

nerve blocks, intrathecal analgesic delivery methods, spinal cord stimulation, neu-

rolytic blocks, and vertebroplasty.5 Injections of neurolytic agents to destroy nerves

and interrupt pain pathways have been used for many years.6 In terminally ill cancer

patients, phenol has been administered using the intrathecal or epidural routes for the

blockade of sympathetic ganglia (celiac, superior hypogastric, ganglion impar, and

so on).7 Current knowledge and techniques allow these procedures to be performed

safely and expeditiously, even though the risk–benefit ratio associated with neurolysis

techniques is narrow. The use of phenol for neuroablation for chronic malignant pain

is widely accepted, especially when the life expectancy is low. We discuss a case of

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Gollapalli and Muppuri

paraplegia followed by phenol intercostal neurolysis for

intractable intercostal neuralgia.

Materials and methodsA 66-year-old Caucasian female was diagnosed with

adenoid cystic carcinoma of the left submandibular gland

in 1997. She had a left radical neck dissection, radiation,

and chemotherapy. In 2005, the patient was diagnosed with

extensive metastases to the pleura, lungs, breast, spleen,

retroperitoneum, and bones. Since 2005, she had multiple

thoracenteses and radiation therapy. The patient complained

of lancinating pain in the left side of the chest, was unrespon-

sive to medical therapy, and was referred to the pain clinic

for interventional management by the oncology care team.

Medical causes of chest pain were ruled out before diagnostic

intercostal nerve blocks were scheduled. She had no signifi-

cant medical problems other than constipation from opioids,

and she had a 20 pack-year smoking history.

The patient was brought to the operating room and was

placed in a prone position. Standard American Society of

Anesthesiologists monitoring was applied, and the patient

received anesthesia with an intravenous midazolam, fentanyl,

and propofol infusion. The patient’s back was prepared and

draped in a sterile fashion. We had decided to proceed with

an intercostal neurolytic block when the patient reported

60%–70% pain relief for about 6–8 hours with a diagnostic

T6 to T12 intercostal nerve block. The left T6 to T12 ribs were

identified 6–7 cm from the midline and marked. The inferior

approach was used to insert a 1.5-inch, 25 gauge needle into

the inferior border of each rib; the needle was advanced until

the periosteum was contacted (Figure 1). The needle tip was

walked off the inferior margin of the rib and advanced 0.5

cm. After negative aspiration, 1 mL of iopamidol dye was

injected, and adequate horizontal spread was seen along the

inferior border. At each level, 2 mL of 10% aqueous phenol

was injected with ease. The patient was sedated well and

did not respond to any verbal commands. No intraoperative

complications were noted.

One hour after the procedure, the patient was awake

and had stable vital signs. However, she had bilateral lower

extremity weakness with difficulty moving. A physical

examination showed an absence of sensation to pinpricks

and vibration from T10 to S5, no voluntary anal contraction,

and an absence of anal sensation. Her bilateral lower extrem-

ity muscle strength was 0/5, and she showed an absence of

deep tendon reflexes. Intravenous methylprednisolone was

given, as per the National Acute Spinal Cord Injury Study

III guidelines.

The patient was admitted, and a neurosurgeon and a

neurologist were consulted. Magnetic resonance imaging

of the thorax and lumbar spine showed extensive bony

metastasis, leptomeningeal metastatic disease, and myelitis

at T6 and below (Figure 2). No surgical intervention was

recommended, and she was referred for physical medicine

and rehabilitation. There was neurogenic bladder dysfunction

requiring intermittent catheterization; rectal emptying had

to be regulated by laxatives. No clinical remission was seen

even after 6 months of rehabilitation; hence, the neurological

deficits were considered persistent.

DiscussionPoorly controlled pain can be devastating and can severely

impair quality of life and activities of daily living.3 Studies

have shown that at least 10%–15% of patients fail to control

pain adequately and will experience severe pain in spite of

analgesic therapy.5 As many as 46% of terminal patients

receive inadequate pain treatment, as reported by family

members.8

Neurolysis of the intercostal nerve appears to be a cost-

effective approach to treating intercostal neuralgia associated

with cancer. The benefits of intercostal neurolysis include

improved analgesia, reduced opioid consumption, and

superior clinical effects, due to the absence of deleterious

Figure 1 Fluoroscopic view of horizontal spread of contrast dye, prone position.Note: The needle tip is seen near the inferior border of T12 rib on the left.

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Paraplegia after intercostal neurolysis

properties of high-dose chronic opioid therapy. Pain practitio-

ners have been performing these blocks as a part of adjuvant

therapy for the optimal treatment of cancer pain.

Phenol, also known as carbolic acid and as hydroxy-

benzene, was introduced in the 1950s.9 It is a colorless,

crystalline substance that has a characteristic odor and is

soluble in water and organic solvents. It has been in use

for neuroablation in chronic cancer pain for a long time.

However, because of the complications that phenol causes,

its use for chemical neurolysis for chronic noncancer pain

is less common. When injected near motor nerves, phenol

can produce flaccid paralysis and might also cause systemic

complications, such as nausea and vomiting, central nervous

system stimulation, cardiovascular depression, and cardiac

arrhythmias.10 Phenol can diffuse from the paravertebral gut-

ter through the intervertebral foramina toward the epidural

space, and then to the cerebrospinal fluid to cause persistent

paraplegia.11

Invasive use of phenol has been shown to cause irre-

versible neural tissue damage, and several complications

have been reported.10,12 There was one case report in which

a patient had persistent paraplegia following an intercostal

block with a 7.5% aqueous phenol solution.11

In our case, the patient could have developed

paraplegia from the diffusion of the phenol along the

spinal nerves or the paravertebral venous plexus into the

subarachnoid space. It is unlikely to be intravascular,

since the symptoms presented about an hour after the

procedure. There is a possibility that rapid infusion of

the drug could have forced the solution to diffuse faster

into the spinal space, even though only 2 mL of phenol

had been used. Paraplegia could also occur from verte-

bral or lymph node metastases or though direct extension

from adjacent primary tumors, such as lung carcinoma,

or through leptomeninges, thereby damaging the motor

and sensory roots in leptomeningeal metastatic disease.

The phenol intrathecal elimination half-life is 8 minutes,

as revealed from the Renografin® solution in monkeys.7

Slow diffusion of phenol through the leptomeninges

at multiple levels leads to neurological damage. Deep

sedation masked the immediate effects of neurological

damage in our case. Leptomeningeal carcinomatosis that

involves the spinal nerves often has a nodular appearance

in which tumor foci appear as a string of beads throughout

the cauda equina and extend out of the nerves into the

neural foramina. Along the spinal cord, a leptomeningeal

tumor typically presents as a thin coating along the pia

mater, although nodularity and diffuse involvement of the

arachnoid space also can occur.

These are some alternative methods to minimize the

neurological complications with intercostal neurolysis in

leptomeningeal metastatic disease:

1. Especially for the blockade of peripheral nerves near the

spine, lipid phenol should be used instead of aqueous

solutions, because diffusion and unwanted damage can-

not be excluded reliably.11 (The use of phenol solutions

in water may result in 50 times higher toxicity than that

of lipid phenol.)13

2. For leptomeningeal metastatic disease, radiofrequency

neuroablation is an alternative treatment method to

phenol for intercostal neurolysis, which is used in the

treatment of the most common chronic nonmalignant

pain syndromes.14

3. Intercostal neurolysis should be performed at the midaxil-

lary line,15,16 far from the costovertebral joint.

4. Mild sedation with patient communication during the

intercostal neurolysis procedure minimizes the chance

of developing permanent neurological damage.

Figure 2 Magnetic resonance images of the thoracic spine, sagittal view, different sections, showing the thoracic body involvement.Note: Extensive metastatic disease of the vertebral body can be seen.

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ConclusionThis case highlights the risk associated with aqueous phenol

application in the vicinity of the spinal cord for leptomenin-

geal metastatic disease. We recommend that patient selection

prior to the interventional pain treatment is very important.

We also recommend that alternative methods be used for

intercostal neurolysis in leptomeningeal metastatic disease

patients whenever possible.

DisclosureThe authors report no conflicts of interest in this work.

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